Part 10 (1/2)

CARDIAC DRUGS

Whether any drug should be used which acts directly on the heart is often a question for decision. As endocarditis is generally secondary to some acute disease, the patient has become weakened already, and the circulation is not st.u.r.dy; therefore such a drug as aconite is probably never indicated. The necessary diminished diet, catharsis, hypnotic, salicylic acid and alkalies all tend to quiet the circulation and diminish any strenuosity of the heart that may be present. Unfortunately, during fever processes, digitalis in ordinary doses rarely slows the heart; and while it might slow the heart if given in large doses, it would also cause too powerful contractions of the ventricles. Digitalis is inadvisable if there is much endocardial inflammation, and especially if there is supposed or presumed to be acute myocardial inflammation. If a patient had already valvular disease from a previous endocarditis, and during this attack insufficiency of the heart was evidenced by pendent edemas, digitalis Should be administered; but it probably should not be given to other patients during the acute period of inflammation.

BATHS

During rheumatism the peripheral blood vessels are generally dilated and the skin perspires profusely. This is caused not only by the rheumatism, but also by the salicylates. The surface of the body should be sponged with cold, lukewarm or hot water, depending on the temperature, especially of the skin. The cold water will reduce the temperature and tone the peripheral blood vessels; the hot water, if the temperature is low and the skin moist and flabby, will cleanse it and also tone the peripheral blood vessels. If the blood vessels are dilated and the perspiration profuse, atropin is indicated, both as a cardiac stimulant and contractor of the blood vessels and as a preventer of too profuse sweating. The dose should be from 1/200 to 1/100 grain for an adult, given two or three times in twenty-four hours, depending on its action and the indications. It should be remembered that atropin is not a sleep-producer; it may stimulate the cerebrum. Therefore at night it might well be combined with a possible necessary hypodermic injection of morphin.

STRYCHNIN

The question of the advisability of strychnin is a constant subject for discussion. Strychnin is overused in the cases of most patients who are seriously ill. In a patient in whom we are trying to cause nervous and muscular rest, strychnin is certainly contraindicated.

On the other hand, if the heart is acting sluggishly, the peripheral circulation is imperfect, and atropin is not acting well, it is advisable to give strychnin in a dose not too large and not too frequently repeated. Strychnin should be avoided, if possible, in the evening in order that the patient may sleep. Whether it should be given by the mouth or hypodermically would depend entirely on the seriousness of the condition. Once in six hours is generally often enough for strychnin to be administered unless the dose is very small.

ALCOHOL

It is rarely, if ever, advisable to use alcohol. In certain instances, however, especially in older patients who are accustomed to alcohol, a little whisky administered several times a day may act only for good, both as a food and as a peripheral dilator. But it must be remembered that alcohol is not a cardiac stimulant, and that a large dose will be followed by more cardiac depression.

Nitroglycerin may act as well as whisky in the kind of cases mentioned. Caffein stimulation in any form is generally inadvisable during inflammation of the heart.

PROGNOSIS AND CONVALESCENCE

The duration of acute endocarditis varies greatly; it may be two or three weeks, or the inflammation may become subacute and last for several months. Although mild endocarditis rarely causes death of itself, it may develop into an ulcerative endocarditis, and then be serious per se. On the other hand, it may add its last quota of disability to a patient already seriously ill, and death may occur from the combination of disturbances. As soon as all acute symptoms have ceased, rheumatic or otherwise, and the temperature is normal, the amount of food should be increased; the strongly acting drugs should be stopped; the alkalies, especially, should not be given too long, and the salicylates should be given only intermittently, if at all; iron should be continued, ma.s.sage should be started, and iodid should be administered, best in the form of the sodium iodid, from 0.1 to 0.2 gm. (1 1/2 to 3 grains), twice in twenty-four hours, with the belief that it does some good toward promoting the resorption of the endocardial inflammatory products and can never do any harm.

Prolonged bed rest must be continued, visitors must still be proscribed, long conversations must not be allowed, and the return to active mental and physical life must be most deliberate.

No clinician could state the extent to which the valvular inflammation will improve or how much disability of the valves must be permanent. It is even stated by some clinicians that a rest in bed for three months is advisable. While this is of course excessive, certainly, when the future health and ability of the patient are under consideration, and especially when the patient is a child or an adolescent, time is no object compared with the future welfare of the person's heart. It is one of the greatest pleasures of a the clinician to note such a previously inflamed heart gradually diminish in size and the murmurs at the valves affected gradually disappear. Although they may have disappeared while the patient is in bed, he is not safe from the occurrence of a valvular lesion for several months after he is up and about.

While the discussion of hygiene would naturally be confined to the hygiene of the disease of which the endocarditis is a complication, still the hygiene of its most frequent cause, rheumatism, should be referred to. Fresh air and plenty of it, and dry air if possible, is what is needed in rheumatism, and a shut-up, over-heated and especially a damp room will continue rheumatism indefinitely. It is almost as serious for rheumatism as it is for pneumonia. Sunlight and the action of the sun's rays in a rheumatic patient's bedroom are essential, if possibly obtainable.

As so many rheumatic germs are absorbed from diseased or inflamed tonsils or from other parts of the mouth and throat, proper gargling or swas.h.i.+ng of the mouth and throat should be continued as much as possible, even during an endocarditis. The prevention of mouth infections will be the prevention of rheumatism and of endocarditis.

MALIGNANT ENDOCARDITIS: ULCERATIVE ENDOCARDITIS

Since we have learned that bacteria are probably at the bottom of almost any endocarditis, the terms suggested under the cla.s.sification of endocarditis as ”mild” and ”malignant” really represent a better understanding of this disease. They are not separate ent.i.ties, and a mild endocarditis may become an ulcerative endocarditis with malignant symptoms. On the other hand, malignant endocarditis may apparently develop de novo. Still, if the cause is carefully sought there will generally be found a source of infection, a septic process somewhere, possibly a gonorrhea, a septic tonsil or even a pyorrhea alveolaris. Septic uterine disturbances have long been known to be a source of this disease.

Meningitis, pneumonia, diphtheria, typhoid fever and rarely rheumatism may all cause this severe form of endocarditis.

Ulcerative endocarditis was first described by Kirkes in 1851, was later shown to be a distinctive type of endocarditis by Charcot and Virchow, and finally was thoroughly described by Osler in 1885.

Ulcerative endocarditis was for a long time believed to be inevitably fatal; it is now known that a small proportion of patients with this disease recover. Children occasionally suffer from it, but it is generally a disease of middle adult life. Ch.o.r.ea may bear an apparent causal relation to it in rare instances.

Ulcerative endocarditis may develop on a mild endocarditis, with disintegration of tissue and deep points of erosion, and there may be little pockets of pus or little abscesses in the muscle tissue.

If such a process advances far, of course the prognosis is absolutely dire. If the ulcerations, though formed, soon begin to heal, especially in rheumatism, the prognosis may be good, as far as the immediate future is concerned. If the process becomes septic, or if there is a serious septic reason for the endocarditis, the outlook is hopeless. This form of endocarditis is generally accompanied by a bacteremia, and the causative germs may be recovered from the blood. One of the most frequent is the Streptococcus viridans.

DIAGNOSIS

If a more malignant form of endocarditis develops on a mild endocarditis, the diagnosis is generally not difficult. If, without a definite known septic process, malignant endocarditis develops, localized symptoms of heart disturbance and cardiac signs may be very indefinite.

If there is no previous disease with fever, the temperature from this endocarditis is generally intermittent, accompanied by chills, with high rises of temperature, even with a return to normal temperature at times. There may be prostration and profuse sweats.